Ocular Trauma

LALU ARIES FAHROZI

Tujuan pembelajaran
Mengetahui riwayat terjadinya trauma

ocular Mengetahui efek dari trauma ocular Memahami manajemen a trauma ocular Memahami dasar-dasar yang berhubungan dengan trauma ocular

Pendauluan
Secara umum mata di lindungi didalam rongga orbita, akan tetapi injury dapat terjadi pada mata, diantara penyeba inury yang paling sering adalah :
Benda asing
Trauma tumpul Penetrating trauma

Chemical and radiation injuries

risk factors
Gender : 75%-80% of them are in males
Age: more in children and young age group Occupation : construction, industry Sports : boxing , racket sports Motor vehicle accidents

Effects of eye injury :

Closed globe injury or Non-penetrating trauma:

The eye globe is intact, but the seven rings of the eye have been classically described as affected by blunt trauma. Penetrating trauma: The globe integrity is disrupted by a full-thickness entry wound and may be associated with prolapse of the internal contents of the eye.

Effects of eye injury (cont.)

Blowout fracture of the orbit is caused by blunt

trauma, classically described for fist or ball injury, leading to fracture of the floor or medial wall of the orbit due to sudden increased pressure on the orbital contents. Perforating trauma: The globe integrity is disrupted in two places due to an entrance and exit wound (through and through injury). This is a quite severe type of eye injury.

Foreign bodies
Corneal foreign body is foreign material on or in the cornea, usually metal, glass, or organic material.

Corneal foreign bodies:

Symptoms
Foreign body sensation, Tearing, History of trauma ,photophobia , pain , red eye

Signs
Corneal foreign body with or without rust ring, edema of the lids, conjunctiva, and cornea, foreign body can cause infection and/or tissue necrosis.

Corneal foreign body

Assesment
1.History 2.Document visual acuity. One or two drops of topical anesthetic may be necessary to control pain. 3.Slit-lamp Examination: If there is no evidence of perforation, evert the eyelids and inspect for foreign bodies. 4.Dilate the eye and examine the vitreous and retina 5.Consider a B-scan USG, CT of the orbit.

Corneal foreign bodies cont.

Treatment
Apply topical anesthetic, remove the foreign body with

a spud or forceps at a slit lamp. If multiple superficial foreign bodies, its easier to remove with irrigation. Remove the rust ring. This may require an ophthalmic drill. Measure the size of the resultant corneal epithelial defect. Treat as for corneal abrasion.

Blunt trauma
Trauma tumpul dapat mengakibatkan kerusakan struktur depan dari mata (the eyelid, conjunctiva, sclera, cornea, iris, and lens) serta struktur belakang dari mata (retina and optic nerve).
If a small objects ( such as a squash ball, shuttlecocks, knuckles, etc.) hits the area the eye itself may take most of the impact. If a large object (such as a football, or by fist) hits the eye most of the impact is usually taken by the orbital margin. Such an impact may also result in damage to the orbit (blow-out fracture).

Penetrating trauma
when a foreign body passes through the ocular coat of the eye, this will cause damage in the ocular structures, and in some cases the foreign body may also be retained in the eye.
penetrating injury of the eye

represents a major threat to vision in the workplace, home and school.

Lid lacerations:

Eyelid Lacerations: Cuts to the eyelid caused by trauma Superficial Lacerations can be usually treated in the emergency room under local anesthesia

Subconjunctival hemorrhage:
Is bleeding underneath the conjunctiva. The conjunctiva

contains many small, fragile blood vessels that are easily ruptured or broken. When this happens, blood leaks into the space between the conjunctiva and sclera. Symptoms Red eye, may have mild irritation, usually asymptomatic Signs Blood underneath the conjunctiva, often in a sector of the eye. The entire view of the sclera may be obstructed by blood. Causes Valsalva (e.g., coughing or straining), Trauma, Bleeding disorder, Hemorrhage due to orbital mass (rare), Idiopathic.

Subconjunctival hemorrhage cont.

Assesment and Management: History: Bleeding or clotting problems? Medications (e.g., aspirin, warfarin)? Eye rubbing, trauma, heavy lifting, Valsalva? Recurrent Subconjunctival Hemorrhage? Acute or Chronic cough (COPD)? Check Vital signs History of recurrence or bleeding problem; order Bleeding time, CT, BT, CBC. Positive Orbital signs: CT scan with and without contrast

The cornea
The cornea is the transparent front part of the eye that covers

the iris, pupil, and anterior chamber. Together with the lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical power Corneal epithelium: a thin epithelial multicellular tissue layer (non-keratinized stratified squamous epithelium Bowmans layer Corneal stroma Descemets membrane Corneal endothelium

Corneal abrasion:
Kondisi medis yang

melibatkan kehilangan/abrasi lapisan epitel dari kornea mata. Terjadi karena adanya trauma fisik eksternal

Corneal abrasion cont.

Umumnya tanpa komplikasi yang serius, tapi jika

abrasinya dalam dapat meninggalkan scar. Examples : corneal or epithelial disease (eg, dry eye, superficial corneal injury or ocular injuries (eg, those d.ue to foreign bodies), and contact lens wear .

Corneal abrasion cont.

Gejala :
Photophobia Watering Foreign body sensation

Gritty feeling
Pain

Tanda : Corneal edema

Bacterial corneal ulcers Fungal, amebic, or viral corneal ulcers ,Uveitis

 Patients may be troubled by recurrent episodes of pain

particulary in the early hours of the morning or on walking. This condition is termed recurrent corneal abrasion It happens due to adhesion of the resurfacing epithelium to bowmans layer at the site of injury Prophylaxis against recurrent corneal erosion can be achieved by using lubricating ointment at night.

Corneal abrasions cont.

Treatment:
Antibiotics
Ointment (Erythromycin, Ciprofloxacin) Drops (Polytrim, Fluoroqunilone)

Patching for comfort,

Topical NSAIDS
pain control. AVOID in post-op patients No contact lens wear

and avoiding scratching of the eye during sleep.

drops (Ketorolac) for

Cycloplegic agent

(Cyclopentolate) for discomfort from traumatic iritis which may develop 24-72 hours. AVOID STEROIDS.

Corneal lacerations:
A corneal laceration

is a partial- or fullthickness injury to the cornea. A partialthickness injury does not violate the globe of the eye (abrasion). A full-thickness injury penetrates completely through the cornea, causing a ruptured globe

Corneal laceration
Partial thickness:
Signs
The Ant. Chamber isnt entered, therefore, the cornea isnt perforated

assesment
1.Complete ocular examination 2.Seidel test : If positive then its a full-thickness laceration. Seidle test: is used to assess the presence of anterior chamber leakage in the cornea.

Corneal lacerations cont.

Treatment
Cycloplegic (Scopolamine)

and an antibiotic (Polysporin, Fluroquinolone drops) If moderate to deep corneal laceration is accompanied by wound gape, it is often best to suture. Tetanus toxoid for dirty wounds

Follow up Reevaluate daily until the epithelium heals.

Corneal lacerations cont.

Full thickness:
We should exclude Ruptured Globe and Penetrating

Ocular injury, A full-thickness injury will allow aqueous humor to escape the anterior chamber, which can result in a flat-appearing cornea, air bubbles under the cornea, or an asymmetric pupil secondary to the iris protruding through the corneal defect. treated with aqueous suppressants, bandage soft contact lenses, fluroquinolone drops. Alternatively, a pressure patch and twice-daily antibiotics may be used. AVOID steroids.

Small, self-sealing, or slow leaking lacerations may be

Hyphema:
Adalah adanya darah pada ruang depan pada mata (anterior chamber)
Symptoms
Pain, Blurred vision, History of

blunt trauma

Signs
Blood in the Anterior Chamber.

Gross layering or clot or both, usually visible without a slit lamp

Hyphema cont.
Pengkajian
1. History: Mechanism of injury, approximate time and day, time of visual loss, Medications (Aspirin, NSAIDs, Warfarin), History or family history of sickle cell disease 2. Complete Ocular Examination 3. CT scan of the orbit 4. Screen for sickle cell disease or trait

Faktor-faktor yg memperburuk
1. Poor visual acuity (worse than 20/200) 2. Sickle cell disease/trait with increased IOP 3. Medically uncontrollable IOP 4. Large initial hyphema 5. Recent Aspirin, NSAIDs use 6. Delayed presentation

Hyphema cont.
Perawatan

Bedrest di RS Posisi kepala 45 Atropine Mild analgesics Topical steroids drops (Traumatic iritis develop 2-3 days) NO aspirin or NSAIDs

Hyphaema

Etiologi
Hyphaemas are frequently caused by injuryBlunt

truma,and it may partially or completely block vision. Complications:

hemosiderosis hetrochromia blood acumulation may also cause

elevtion of the intraocular pressure

Blow Out Trauma

A blowout fracture is a fracture of the walls or floor of the orbit. Intraorbital material may be pushed out into one of the paranasal . This is most commonly caused by blunt trauma of the head

Blowout fracture
Symptoms: Pain (especially on attempted vertical eye movement) Local tenderness Binocular double vision Eyelid swelling And creptius after nasal blowing Sign: Emphysema (air under the skin with crackles when pressed) derived from the fractured sinus. Parasthesia below the orbital rim suggesting infraorbital nerve damage Limitation of eye movement , particularly on upgaze and downgaze , due to tethering of the inferior rectus muscle .

Blowout fracture cont.

Treatment

Broad spectrum oral antibiotic Instruct the patient not to blow his nose Apply ice packs to the orbit for the first 24 to 48 hours The aim of treatment is prevention of permanent diplopia and cosmetically unacceptable enophthalmos. The factors that determine the risk of late complications are -Fracture size -Herniation of orbital content into the maxillary sinus -Muscle entrapment Surgical repair -Immediate repair (usually within 24 hr.) -Repair in 1 to 2 weeks Neurosurgical consultation is recommended

Chemical burn
Most chemical substances that come in contact with the

conjunctiva or cornea cause little harm.

The chief danger comes from alkali-containing compounds

found in household cleaning fluids, fertilizers and pesticides. They erode and opacify the cornea. are somewhat less dangerous.

Acid-containing compounds (battery fluid, chemistry labs)

There are no antidotes to these chemicals. The best you can

do is to dilute them immediately with plain water.

The resultant reaction of the tissue causes the damage.

Treatment
Emergency treatment: Copious irrigation of the eyes, preferably with saline or ringer lactate. Dont use acidic solutions to neutralize alkalis or vice versa. Pull down the lower eyelid and evert the upper eyelid to irrigate the fornices Irrigation should be continued until neutral PH is reached. The volume of irrigation fluid required to reach neutral PH varies with the chemical and the duration of the chemical exposure

Chemical burn
For mild to moderate burns (during and after irrigation): cycloplegic topical antibiotic oral pain medication if increase IOP use drugs to reduce it (acetazolamide, methazolamide add b blocker if additional IOP control is required) frequent use of preservative free artificial tear

Chemical burn
For severe burns (Treatment after irrigation): Admission to the hospital Lysis of conjunctival adhesion Debride necrotic tissue Topical antibiotic Topical steroid Consider a pressure patch Antiglaucoma medication if the IOP is increased or cant be determined Frequent use of preservative free artificial tear

Chemical burn (injury)

A hazy cornea following an alkali burn